FWP Registration JAN 2024- Cohort 1 Question Title * 1. First and Last Name Question Title * 2. Email Address: Question Title * 3. D/O/B: Question Title * 4. Cell Phone Number [ex. (area code)-123-4567] Question Title * 5. Do you live in Detroit? Yes No Question Title * 6. Address Address Address 2 City/Town State/Province ZIP/Postal Code Question Title * 7. How many family members, including yourself, do you currently live with? Question Title * 8. How would you describe your ethnic group? (select all that apply) White or Caucasian Black or African American Hispanic or Latino Asian or Asian American American Indian or Alaska Native Native Hawaiian or other Pacific Islander Biracial/ Multiracial Question Title * 9. Please specify your gender Female Male Non binary Other Prefer not to answer Question Title * 10. What is your marital status? Married Common law Separated Divorced Single Widowed Question Title * 11. What is the highest level of school that you have finished? Completed 4 years of college or more. Completed 2 years of college. Completed some college. High school diploma or GED Less than a high school degree Question Title * 12. What is your household income? Under $15,000 Between $15,000 and $29,999 Between $30,000 and $49,999 Between $50,000 and $74,999 Between $75,000 and $99,999 Between $100,000 and $150,000 Over $150,000 Question Title * 13. What language are you most comfortable speaking? Question Title * 14. What is your current work situation? Employed (fulltime) Employed (parttime) Contract/ Seasonal/ Temporary Unemployed Self employed. Retired Question Title * 15. Do you participate in any of the following programs? [Select all that apply] SNAP/Food Benefits (Supplemental Nutrition Assistance Program) FAP (Food Assistance Program) FIP/TANF/AFDC/Cash Benefits WIC Head start/Early Head start Energy Assistance Other Question Title * 16. How did you hear about the program? Phone (via Text or Call) Social Media Brillian Detroit Referral Other Question Title * 17. Select your preferred Brilliant Detroit Neighborhood Hub I am not affiliated with a Brilliant Detroit Hub Spring wells Brilliant Site: 9104 Rathbone, Detroit, MI 48209 Southwest Site: 5675 Larkins St, Detroit, MI 48210 Osborn Brilliant Site: 13800 Eastburn Street, Detroit, MI 48205 Morningside Brilliant Site: 5048 Balfour Rd., Detroit MI 48224 Martin Park Brilliant Site: 16587 La Salle Ave Detroit, MI 48221 Littlefield - 12789 Indiana Ave, Detroit, MI 48238 Fitzgerald Brilliant Site: 16919 Prairie, Detroit, MI 48221 Dexter-Linwood Brilliant Site: 2634 Webb, Detroit, MI 48206 Cody Rouge Brilliant Site: 7425 Fielding, Detroit, MI 48228 Chandler Park - 5312 Newport, Detroit, MI 48213 Central Detroit Brilliant Site: 803 Hazelwood, Detroit, MI 48202 Brightmoor Brilliant Site: 15509 Heyden, Detroit, MI 48223 Question Title * 18. Please select the session you would like to attend. Tuesday afternoon 4:00pm Wednesday morning 11:00am Wednesday afternoon 4:00pm Question Title * 19. Have you participated in this program before? Yes No Question Title * 20. Do you understand that an onboarding session is required before the program begins, in which you will visit for a quick intake of metrics (weight, blood pressure, receiving the curriculum, etc.) THIS SHOULD NOT TAKE MORE THAN 15-20 MINS. Yes No Done